BLOOM: BuiLding healthy thinking to OvercOme Maternal depression
Across much of rural sub-Saharan Africa, pregnancy and early motherhood unfold in the presence of compounding challenges: food insecurity, poverty, social isolation, and limited access to health services. Emotional suffering during this period is common, and perinatal depression is associated with poor self-care, impaired mother-infant bonding, preterm birth, low birth weight, and compromised offspring physical and neurodevelopment. Yet, mental health services are rarely available. In many regions, more than 90% of individuals with mental health conditions receive no treatment at all. Standard treatment options become even more limited when considering the low literacy population of regions such as rural Pujehun District, Sierra Leone.
PPB set out to change this reality and create the first highly effective mental health service in these communities by developing a cognitive behavioral therapy (CBT) intervention adapted for perinatal women with depression.
The Novel Program
Most evidence-based mental health therapies, including CBT, depend heavily on written worksheets, reading exercises, and homework assignments. In many rural communities, however, literacy cannot be assumed, and this reality often places effective psychological care out of reach for the women who may need it most.
PPB designed this counseling program specifically for non-literate perinatal women. Rather than simplifying a standard therapy, the team re-imagined how CBT could work without written materials. Sessions are conducted entirely through conversation, storytelling, guided reflection, drawings, and role-play; approaches that align naturally with local ways of learning and sharing knowledge. The result is therapy that feels personal, respectful, and immediately relevant to daily life.
The Counselling
Counselling takes place wherever a private session can be held. Participants are encouraged to openly communicate with their counselors in confidence. Sessions are led not by psychiatrists, but by trained local women who share language, culture, and life experience with the mothers they support. This not only fosters trust in the counselors, but allows sustained relationships between the counselor and participant.
Each woman meets individually with a counselor for five weekly sessions and a group session, lasting about an hour. These sessions are practical and collaborative. Together, the counselor and participant:
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Talk through the problems weighing most heavily on her life
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Identify small, realistic goals she feels able to try
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Practice new ways of thinking and responding to daily challenges
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Reflect on what worked, what didn’t, and what to try next
Proven Results
This counseling approach has been rigorously evaluated in a randomized clinical trial published in JAMA Network Open (May 2026), making it one of the first CBT programs for perinatal depression tested in a low-literacy, rural African setting with no pre-existing mental health services.
The results were striking: 96% of women in the counseling group experienced clinically meaningful reductions in depression scores, versus 55.4% in the control group. Crucially, these benefits lasted. Women who received counseling continued to show lower rates of depression at 1.5, 3, and 9 months after delivery.
The full trial can be found here.
The trial confirmed that trained local women, with no clinical or mental health background, can deliver cost-effective, evidence-based psychological care in even the most resource-limited settings.
What's Next: BLOOM
Building on the proven results of the Pujehun trial, PPB has launched BLOOM — BuiLding heaLthy thinking to OvercOMe maternal depression — a national effort to bring this counseling program to women across Sierra Leone.
BLOOM is an expansion, not another trial. The evidence has been established. Now the goal is to deliver this care at a larger scale, understand how it performs across diverse settings, and build the foundation for a permanent national program.
The Scale
BLOOM will operate across 10 districts in Sierra Leone, with counseling delivered at 50–80 government-run antenatal and postnatal clinics. A team of 5 trained lay counselors per district, 50 counselors in total, will provide the same six-session program proven effective in Pujehun, supervised by the Mental Health Coalition–Sierra Leone. The program is conducted in partnership with Sierra Leone's Ministry of Health.
Over the course of 36 months, BLOOM aims to reach 20,000 to 30,000 women with depression who would otherwise receive no mental health care at all.
What BLOOM is Measuring
Beyond delivering care, BLOOM will rigorously track the program as it scales to a broader audience — measuring session completion, depression remission rates, and effectiveness holds across different districts, counselors, and levels of baseline severity. Results will be compared directly against the published trial to assess how well the program translates from controlled research to real-world health systems.
The Bigger Question
BLOOM is designed to answer a question that matters well beyond Sierra Leone: can community-delivered, literacy-adapted counseling reduce maternal depression across an entire health system? If the answer is yes, this model that is cost-effective, locally led, and sustainable with no requirement of clinical infrastructure could serve as a blueprint for maternal mental health care in low-resource settings worldwide.
